Understanding Dental Code D5916

When to Use D5916 dental code

The D5916 dental code is designated for the fabrication of an ocular prosthesis, commonly known as an artificial eye. This CDT code should be used when a patient requires a prosthetic replacement due to the loss or absence of an eye, whether from trauma, disease, or congenital conditions. Dental practices may encounter this code in multidisciplinary cases involving maxillofacial prosthodontics, especially when collaborating with oral surgeons or medical professionals. It’s crucial to use D5916 only when the service provided matches the code’s description—fabrication and fitting of an ocular prosthesis—not for repairs or adjustments, which have separate codes.

Documentation and Clinical Scenarios

Accurate documentation is essential for successful billing and reimbursement. When using D5916, ensure the patient’s chart includes:

• Detailed medical and dental history, including the reason for eye loss
• Clinical notes describing the need for an ocular prosthesis
• Pre- and post-operative photos (if applicable)
• Referral notes from ophthalmologists or surgeons
• Lab prescriptions and correspondence with the dental laboratory

Common clinical scenarios include post-enucleation or evisceration cases, congenital absence of the eye, or trauma resulting in loss of the globe. In each scenario, thorough documentation supports the medical necessity for the prosthesis and helps prevent claim denials.

Insurance Billing Tips

Billing for D5916 requires attention to detail and proactive communication with payers. Here are actionable steps for successful claims:

1. Insurance Verification: Before treatment, verify the patient’s benefits and confirm whether ocular prostheses are covered under dental or medical insurance. Many plans consider this a medical benefit.
2. Preauthorization: Submit a preauthorization request with supporting documentation, including clinical notes, diagnostic codes (such as ICD-10), and letters of medical necessity.
3. Claim Submission: Use the correct CDT code (D5916) and ensure all required attachments—photos, referral letters, and lab invoices—are included. Double-check patient and provider information for accuracy.
4. Follow Up: Monitor the claim status regularly. If you receive an EOB with a denial or reduction, review the reason codes and prepare a claim appeal with additional supporting documentation if needed.
5. Coordination of Benefits: If both dental and medical insurance are involved, coordinate benefits to maximize reimbursement and avoid duplicate billing.

Staying organized and maintaining clear communication with both the patient and the insurance company streamlines the process and reduces AR days.

Example Case for D5916

Consider a patient who lost an eye due to a workplace accident. The dental team receives a referral from an ophthalmologist for an ocular prosthesis. The office manager verifies the patient’s medical insurance covers prosthetic eyes, obtains preauthorization, and collects all necessary documentation. The prosthodontist fabricates and fits the ocular prosthesis, documenting each step. The claim is submitted with D5916, accompanied by operative notes, referral letters, and photos. The insurance approves the claim, and payment is posted promptly, thanks to thorough preparation and adherence to best practices.

By following these steps, dental offices can ensure accurate billing, timely reimbursement, and optimal patient care when using the D5916 dental code.